Week 6 Flashcards
72 year old woman with COPD presents with 1/52 dry cough, increased SOBOE and wheeze. No pleuritic CP, no haemoptysis.
- O/E: looks well, apyrexial, RR 16, SpO2 99%. Chest no focal signs, wheezy throughout, bibasal crackles.
a) Likely cause?
b) Management? - also check what?
c) When would bone protection be necessary?
a) Non-infective/viral exacerbation of COPD
b) - 5/7 oral prednisolone 5mg (6 doses per day = 30mg)
- Book in for influenza vaccine when well
- Worsening advice given
- Explained that abx not necessary in this instance
- Check if they have rescue meds at home
c) Requiring frequent steroid courses (3-4 per year)
39 year old man with 8 year history of snoring. Causing him to sleep in different bedroom to wife. No history of trauma, no ENT issues. Wakes up breathless some nights and also some daytime sleepiness. Otherwise fit and well.
a) What examinations must be performed?
b) What score must be calculated to determine eligibility for referral?
c) What is the management in this case?
a) Height, weight (BMI) and neck circumference. Also examine ENT (sniff test for nostril patency)
b) Epworth Sleepiness Score (ESS): If >10 can refer for sleep study
c) - Bloods for FBC and TFTs before referral
- If normal, refer for overnight sleep study
- Counselled that if OSA can treat with CPAP but if simple snoring very little that can be offered.
52 year old female with OA complaining of worsening bilateral knee pain. Takes 1-2 ibuprofen/day but gets some gastric irritation and occasional co-codamol but doesn’t like taking these. Exercises regularly and still under PT. Previously took Nefopam in 2015 and felt these worked well. Had IA steroid in shoulder and wants to know if this is possible for her knees.
a) What Qs to ask for worrying mechanical knee obstruction?
b) Management from here
c) What should you advise her about the Nefopam and the steroid injections?
d) When would surgery be considered
Also mentions PR bleed (3 days, 3 weeks ago), mixed in with stool and fresh. Some diarrhoea. Puts it down to taking ibuprofen
e) How would you manage this?
f) Effect of NSAIDs and PPIs on colitis
a) Locking or giving way
b) - Regular analgesia with NSAID less likely to damage stomach (e.g. meloxicam) and PPI
- Continue with PT and exercise
c) - Nefopam (like opioids) is good for acute pain but in the long term causes tolerance and dependence so not advised for OA
- IA steroids provide short-term benefit but she needs regular long-term pain control before this can be considered
d) Symptoms of joint pain, stiffness, and functional impairment are refractory to primary care management and significant impact on QoL.
Generally knee replacements, but if hx of mechanical locking - consider joint debridement
e) PR exam - if no obvious cause (eg pile, fissure) found, then refer for flexi sig.
f) - NSAIDs can worsen symptoms in IBD (but should not cause fresh bleeding - may cause melaena due to UGIB)
- PPIs can result in microscopic colitis (causes chronic watery diarrhoea)
62 year old male with COPD presents with 2/7 cough, bringing up clear phlegm. Inc wheeziness, chest tightness and salbutamol use (QDS). No red flags.
-o.e: looks well, apyrexial, 99% SpO2, chest clear. Smokes 10 per day.
a) Advice - when to take pred/when to take abx
b) Management
a) Increased SOB/wheezy/chest tightness - 5/7 pred
- Purulent/thick/increased sputum - 5/7 abx
b) - Check rescue med prescription
- Self care and rescue med advice
- Review inb
- Advise smoking cessation
29 year old female with 2/7 itchy rash inside umbilicus. Applying Sudocrem, not taken anything else. No lesions elsewhere. No fevers. Otherwise and well. No previous rashes. No skin conditions.
-o/e: mild erythema, no discharge, no tenderness
a) Likely cause
b) Management
a) Fungal skin infection (intertrigo - ?candida)
b) Antifungal/corticosteroid:
Timodine cream - nystatin, hydrocortisone
68 year old female with 1/12 history of red, swollen legs. Treated with 4 different antibiotics over this period, for suspected cellulitis. None have worked. No fevers or systemic upset. Recent bloods showed normal FBC/CRP. Has eczema, lymphoedema and recurrent cellulitis.
- O/E: looks well, apyrexial.
Bilateral erythema and swelling from foot to below knee. Mild tenderness. No pitting.
a) Why cellulitis is unlikely
b) Possible diagnosis
c) Management
a) Bilateral, normal WCC and CRP, resistance to 4 different antibiotics
b) Infected eczema
c) - Trial Fucibet (fusidic acid/ betamethasone) cream for suspected infected dermatitis - advised to use 30 mins after emollient application
- Consider speaking to lymphoedema service/TVN about new stockings - may have triggered recent dryness
- Review inb next week
48 year old female with 1 year history of back and flank pain, presents with worsening pain and tenderness on both sides. Lump also felt on left flank. Pain lying on either side. No pleuritic CP, no pain on coughing or movement. Takes PRN amitryptilline and co-codamol.
- O/E: tenderness in infero-posterior ribcage and flanks. Good ROM. Chest clear. No lumps felt.
a) In any presentation of an abdominal lump, what should you do on examination?
b) Likely diagnosis
c) If there is swelling over affected joint - this is called…?
d) Management
a) Cough impulse, sit up (hernia - bulge)
b) Costochondritis (though there is usually hx of recent illness, coughing or trauma; and pain usually worse on inspiration, coughing and sneezing)
c) Tietze’s syndrome (more localised than costochondritis)
d) NSAIDs
72 year old female, 5/7 RUQ pain came on suddenly. No radiation. Lies flat with pain. Paracetamol not worked. Normal BO and PU. No vomiting. No fevers. Thinks may be related to food, but not reflux type pain.
-O/E: mild RUQ tenderness, otherwise NAD
a) Likely diagnosis
b) Management
a) Gallstones
b) - NSAIDs for pain
- Worsening advice (fevers, jaundice, etc.)
- USS gallbladder
85 year old lady with 3/52 watery diarrhoea, with alternating hard stools. Some abdominal pain and bloating also. Some nausea but no vomiting. No PR bleed. Possible weight loss and loss of appetite. No dyspepsia or dysphagia. Takes omeprazole.
- O/E: Looks well, abdo SNT, BS present
a) What are the most common causes of diarrhoea and what further questions should therefore be asked?
b) Differentials in this case
c) Management
d) What is a FIT stool sample? How does it differ to FOB? When is it recommended?
a) Infective - close contacts, food sources, etc. Drug-induced - any changes, especially recent ABx.
b) Diverticular disease, colorectal Ca, omeprazole-induced microscopic colitis
c) - Bloods - FBC, CRP, UEs, TFTs
- Stool sample - microbiology
- 2WW - colonoscopy
d) - Faecal immuno-chemical test
- Uses antibodies that specifically measure the amount of human haemoglobin (FOB was not specific to human Hb so would also be positive if animal Hb ingested in food was present)
- Recommended in patients with unexplained symptoms without rectal bleeding and don’t meet the 2WW criteria
31 year old man presents with 3/7 hx of right ear pain and fullness. Has ongoing URTI. No discharge, hearing loss or vertigo, but feels off balance.
- O/E: Right ear canal red and bulging TM
a) What are the signs of a bulging TM?
b) What else is important to examine/ comment on during examination?
c) Likely diagnosis
d) Management
a) Dilated blood vessels, purulent bulging behind drum
b) - Ear - outer ear erythema, pain on manipulation, wax
- Throat - large adenoids
- Mastoid swelling and tenderness
- Lymph nodes- preauricular
c)
d)
Acute otitis media.
a) Common presentation
b) Management
c) Complications
a) Earache. Younger children: holding/rubbing ear, non-specific symptoms (fever, cyring, poor feeding, rhinorrhoea, etc.)
TM - red, yellow/cloudy, may be bulging
b) Most cases - no/delayed abx (amoxicillin 5-7 days)
Systemically unwell/high risk of complications - immediate abx
- All cases - paracetamol/ibuprofen PRN for pain/fever
c) Recurrence, hearing loss, tympanic membrane perforation. Rarely: mastoiditis, meningitis, intracranial abscess, sinus thrombosis, and facial nerve paralysis.
73 year old male with heart failure presents with worsening leg swelling. Worse in right leg. Full time carer so struggling to sit down for a break. Increasing SOB. Sleeps upright with 5-6 pillows. Takes 40mg furosemide, eGFR 29.
-O/E: chest clear. Legs - swollen and pitting up to calf, varicosities present bilaterally. No marked tenderness.
a) Signs of possible DVT
b) Management
a) New changes, increased pain, unilateral changes (>3cm swollen vs other leg, unilateral tenderness and varicosities).
b) Two options:
- Trial furosemide increase from 40mg to 60mg and monitor renal function tightly
- Conservative measures: elevation, compression
Also, TCI if worsening pain or swelling, or worsening SOB
40 year old female presents with continuing pain in left ankle for 4/52 despite starting 10mg amitryptilline 2 weeks ago. No hx of trauma. Also taking ibuprofen 2x TDS. Pain feels unrelated to lower back, localised to ankle. Hx of several operations in both feet, secondary to ?CMT.
- O/E: tenderness posterior to left lateral malleolus. Pain increased on movement.
a) Likely diagnosis
b) Management
a) Bony deformities secondary to CMT/previous operations, possible OA, trapped nerve, etc.
b) XR left ankle. Refer to orthopaedics.
Bursitis.
a) Common locations
b) Causes (2 differentiations)
c) Findings common on examination
d) Management
a) Pre-patellar, olecranon
b) - Septic: usually with systemic fx (fever, malaise, localised cellulitis)
- Non-septic: trauma, overuse, gout, rheum (RA, SLE, sarcoid)
c) Fluctuant swelling (may be red, warm, tender), maximal pain at extreme flexion of joint (when bursa is compressed most), generally normal ROM (indicating pathology not intra-articular)
d) - If confident non-septic bursitis: conservative measures (RICE, analgesia, avoidance of activities that worsen eg prolonged kneeling)
- If septic cause cannot be ruled out: aspirate bursal fluid and commence Abx (eg flucloxacillin)
50 year old woman with 2 months history of right knee pain. No redness or swelling. No locking, occasional giving way. No hx of trauma. No hx of knee problems or any other joints. No systemic illness.
- O/E: Pain in medial joint, pain on movement but good ROM and no ligament damage.
a) Likely diagnosis
b) Management
a) OA. DDx: cartilage damage
b) - Advise self care strategies for 3 months including exercise. PT if patient motivated
- If not, XR knee and take it from there.
- Note: orthopaedics won’t take referral unless conservative strategies have tried and failed
